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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE?QUEST <br /> 58 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> ay <br /> FACILITY NAME -�VV\Vhv V C-e �£C p <br /> SITE ADDRESS <br /> '-\ <br /> �A 1 , . ^0 w�;� <br /> Street Number Direction 1✓ I StrAN ame City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> t ) <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Err. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this fon-n. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT isnot the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: WwC'1 t, \-v-(`e CC- vv \— <br /> COMMENTS:SeC\)—%C'e— 'K7 %V\'Se <br /> CC-�vh.Nr ky <br /> v` bA kA Q�. <br /> ACCEPTED BY: J�/�� � EMPLOYEE#: o cro DATE: 10/1`'I� <br /> ASSIGNED TO: '"` EMPLOYEE#: L 0 0 0 DATE: 16116 i11-:5 <br /> Date Service Completed (if already completed): lSERICE CODE: P/E: 4 7 )� ILZp` OO ` <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />